TESTIMONIAL & MEDIA RELEASE FORM

Leave a testimonial

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Testimonial Consent

I, the undersigned, voluntarily provide a testimonial, statement, or feedback regarding the services I received from Hillary Black / AskHillaryBlack.com (the “Provider”).

I grant permission for my testimonial to be used for marketing, promotional, and educational purposes, including but not limited to: websites, social media, emails, sales pages, presentations, printed materials, and digital products.

I understand that my testimonial may be edited for clarity or length, but not in a way that alters its original meaning.

Name & Identification Permissions

Please check all that apply to indicate how my identity may be displayed with my testimonial:

Professional Information

My job title may be used

My job title may NOT be used

Location Information

City and state initial (e.g., San Diego, CA)

City only

State only

No location information

Photo / Video / Image Usage Permission (Optional)

If I have submitted or recorded a photograph, image, or video of myself (including headshots, profile photos, recorded video testimonials, live session recordings, screenshots, or other likenesses), I grant permission for Hillary Black / AskHillaryBlack.com to use that content in connection with my testimonial for marketing, promotional, and educational purposes.

This may include use on websites, social media, emails, sales pages, presentations, printed materials, and digital products.

Please indicate your preference:

Yes, you may use my photo(s), image(s), and/or video(s) with my testimonial

Yes, you may use my photo(s), image(s), and/or video(s) without my testimonial

No, I do NOT give permission to use my photo(s), image(s), or video(s)

I understand that:

This permission applies only to content I have voluntarily submitted or knowingly recorded
My likeness will not be used in a misleading way
My photo, image, or video will not be sold or licensed to third parties

This consent applies only to media content voluntarily provided by me and does not authorize the use of any images or recordings captured without my knowledge or consent.

Testimonial

“Please share your experience in your own words. Feel free to focus on what shifted for you, what you found most valuable, or how the service supported you.”

Additional Permissions (Optional)

Multi choice

My testimonial may be shared indefinitely

My testimonial may be used in paid advertising

My testimonial may be used in video, audio, or written formats

Confidentiality & Disclaimer

I understand that results may vary and that my testimonial reflects my personal experience. I acknowledge that no guarantees or promises of specific outcomes have been made to me.

I release Hillary Black, AskHillaryBlack.com, and all affiliated businesses from any liability related to the use of my testimonial as authorized above.

Agreement & Signature

By signing below, I confirm that I have read and understand this release and give my full consent.

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